Concussions in Sport

Information and Presentation Materials Courtesy OfDr. Victor Lun, CCFP, DIP Sport Med, Dr. Connie Lebrun, Medical Director – CSFDr. Bob Morell, Member FIS Medical Committee, Tara Fontenot – USSA ATC/PT

Outline

All Sports are subject to Concussion Exposure

• Mechanism of Injury

• Concussion Guidelines

• Clinical Evaluation

• Return to Play

Management

• Concussion Prevention

• Recurrent Concussions

Concussion - Mechanisms

•Rapid deceleration•Extension-flexion movement•Rotation•Skiing – fall on the back of the head

Concussion - Mechanisms

Old Concussion Guidelines

27+ different grading systems in

literature !!

No universal agreement with regards to injury definition and return to play guidelines

Old Concussion Guidelines

Common elements: memory, loss of consciousness, and symptoms

Used to assess severity of a concussion

Poor prognostic value

Varying return to play timelines

New Concussion Classification

Simple

Complex

Summary and Agreement Statement of the 2nd International Symposium on Concussion in Sport. Clin J Sports Med 15(2): 48-56 , 2005

What is a Simple Concussion?

Symptoms?Pattern of gradual resolutionWithout complicationResolution over 7-10 days

Memory dysfunction?Transient

Loss of Consciousness?Transient / “blacked out” < 15 Sec.

What is a Complex Concussion?

Symptoms?Convulsions> 10 days

Loss of Consciousness?> 1 minute

Referral to sports concussion specialist recommended

Simple or Complex??

History

Physical exam

Serial assessment-SCAT

Retrospective Diagnosis

Evaluation - History

Circumstances of injurySymptoms immediate post injury Current symptomsAsk patient, family member, coach etc.

to corroborateCheck video if available

Evaluation – Symptoms

Note: > 90% of sport-related concussion have no L.O.C.

Any sports

Sport Concussion Assessment Tool (SCAT)

• Provides an easy to use tool

•Standardized tool

•Patient education and physician assessment of sport concussion

•Combination of existing tools

Sport Concussion Sport Concussion Assessment Tool (SCAT)Assessment Tool (SCAT)

SCAT – Symptom Scale

SCAT Evaluation - Examination

NeurocognitiveModified Maddocks questions5 word recall (immediate & delayed)months of year in reversereverse digits (string of 5 or 6)

Neurological examSpeechEye motionPronator DriftGait/ Balance Assessment

Return-to-Play Management

If concussion is suspected:

Remove from activity and observe

If prolonged LOC or neurological concerns, C-spine precautions and hospital assessment

Return-to-Play ManagementPhysical RestPhysical Rest

• No “light” exercise or cross training

• No weight training

• No physical activity until symptom free!

• Rest - Rest - RestRest - Rest - Rest

Return-to-Play Management

Cognitive RestCognitive Rest

• Limited School, computer work,

• No !!! - Video games

• Rest - Rest - RestRest - Rest - Rest

Return-to-Play Management

Rest for how long?Rest for how long?

If rapid and full recovery, then 24-48 hours – this is not the return to

physical activity time frame.

For the same amount of time as it took to become asymptomatic ( no symptoms i.e headaches etc.)

Return-to-Play Management

Neuropsychological Testing Detecting cognitive abnormalities

Memory, concentration, “information processing”

Best when compared to baseline data – many teams are now doing baseline testing to establish a norm for each competitor

Return-to-Play Management Neuropsychological TestingWeb-based Types: Traditional 6

hour battery programs

www.cogsport.com www.impacttest.com

Return-to-Play Management Graded Exercise Challenge

Exercise

Aerobic x 10 min HR<130 bpm Aerobic x 30 min with intervals

Protected sport-specific practiceFull sport-specific practice

Return to sport

Return-to-Play Management Graded Exercise Challenge

24 hours per step24 hours per step If there is recurrence of symptoms at If there is recurrence of symptoms at

any stage, return to step 1any stage, return to step 1

Return to Play Management

Other factors Ready to return (confidence) Equipment

Helmet and Mouthguard

How Many ConcussionsAre Too Many?

Lack of agreement on number of concussions “allowed” before termination of season or career

Evidence of cumulative effectWith each successive concussion:

Lower threshold for injuryMore severe symptomsLonger lasting symptomsRisk of subsequent injury higher

Managing Recurrent Concussion ● Longer period of asymptomatic rest

before starting graded exercise challenge

● Extend the time for each stage of exercise protocol

● Take period of time/season off if showing lower threshold / longer recovery

● More conservative with younger patient (“susceptibility”?)

Operative Words For Technical Delegates

When In Doubt When In Doubt

Keep The Athlete Out Of CompetitionKeep The Athlete Out Of Competition

Utilize The Medical Release FormUtilize The Medical Release Form

-HELMETS-All Helmets

Are Not Created Equal

No Matter How They May Look